Bill Text: TX HB3924 | 2021-2022 | 87th Legislature | Enrolled


Bill Title: Relating to health benefits offered by certain nonprofit agricultural organizations.

Spectrum: Slight Partisan Bill (Republican 25-10)

Status: (Enrolled) 2021-06-01 - Sent to the Governor [HB3924 Detail]

Download: Texas-2021-HB3924-Enrolled.html
 
 
  H.B. No. 3924
 
 
 
 
AN ACT
  relating to health benefits offered by certain nonprofit
  agricultural organizations.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle C, Title 8, Insurance Code, is amended
  by adding Chapter 1275 to read as follows:
  CHAPTER 1275. BALANCE BILLING PROHIBITIONS AND OUT-OF-NETWORK
  CLAIM DISPUTE RESOLUTION FOR CERTAIN PLANS
  SUBCHAPTER A. GENERAL PROVISIONS
         Sec. 1275.001.  DEFINITIONS. In this chapter:
               (1)  "Enrollee" means an individual enrolled in a
  health benefit plan to which this chapter applies.
               (2)  "Usual and customary rate" means the relevant
  allowable amount as described by the applicable master benefit plan
  document.
         Sec. 1275.002.  APPLICABILITY OF CHAPTER. This chapter
  applies to a health benefit plan offered by a nonprofit
  agricultural organization under Chapter 1682.
         Sec. 1275.003.  BALANCE BILLING PROHIBITION NOTICE.
  (a)  The administrator of a health benefit plan to which this
  chapter applies shall provide written notice in accordance with
  this section in an explanation of benefits provided to the enrollee
  and the physician or health care provider in connection with a
  health care or medical service or supply provided by an
  out-of-network provider. The notice must include:
               (1)  a statement of the billing prohibition under
  Section 1275.051, 1275.052, or 1275.053, as applicable;
               (2)  the total amount the physician or provider may
  bill the enrollee under the enrollee's health benefit plan and an
  itemization of copayments, coinsurance, deductibles, and other
  amounts included in that total; and
               (3)  for an explanation of benefits provided to the
  physician or provider, information required by commissioner rule
  advising the physician or provider of the availability of mediation
  or arbitration, as applicable, under Chapter 1467.
         (b)  The administrator shall provide the explanation of
  benefits with the notice required by this section to a physician or
  health care provider not later than the date the administrator
  makes a payment under Section 1275.051, 1275.052, or 1275.053, as
  applicable.
         Sec. 1275.004.  OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION.
  Chapter 1467 applies to a health benefit plan to which this chapter
  applies, and the administrator of a health benefit plan to which
  this chapter applies is an administrator for purposes of that
  chapter.
  SUBCHAPTER B. PAYMENTS FOR CERTAIN SERVICES; BALANCE BILLING
  PROHIBITIONS
         Sec. 1275.051.  EMERGENCY CARE PAYMENTS. (a)  In this
  section, "emergency care" has the meaning assigned by Section
  1301.155.
         (b)  The administrator of a health benefit plan to which this
  chapter applies shall pay for covered emergency care performed by
  or a covered supply related to that care provided by an
  out-of-network provider at the usual and customary rate or at an
  agreed rate. The administrator shall make a payment required by
  this subsection directly to the provider not later than, as
  applicable:
               (1)  the 30th day after the date the administrator
  receives an electronic claim for those services that includes all
  information necessary for the administrator to pay the claim; or
               (2)  the 45th day after the date the administrator
  receives a nonelectronic claim for those services that includes all
  information necessary for the administrator to pay the claim.
         (c)  For emergency care subject to this section or a supply
  related to that care, an out-of-network provider or a person
  asserting a claim as an agent or assignee of the provider may not
  bill an enrollee in, and the enrollee does not have financial
  responsibility for, an amount greater than an applicable copayment,
  coinsurance, and deductible under the enrollee's health benefit
  plan that:
               (1)  is based on:
                     (A)  the amount initially determined payable by
  the administrator; or
                     (B)  if applicable, a modified amount as
  determined under the administrator's internal appeal process; and
               (2)  is not based on any additional amount determined
  to be owed to the provider under Chapter 1467.
         Sec. 1275.052.  OUT-OF-NETWORK FACILITY-BASED PROVIDER
  PAYMENTS. (a)  In this section, "facility-based provider" means a
  physician or health care provider who provides health care or
  medical services to patients of a health care facility.
         (b)  Except as provided by Subsection (d), the administrator
  of a health benefit plan to which this chapter applies shall pay for
  a covered health care or medical service performed for or a covered
  supply related to that service provided to an enrollee by an
  out-of-network provider who is a facility-based provider at the
  usual and customary rate or at an agreed rate if the provider
  performed the service at a health care facility that is a
  participating provider. The administrator shall make a payment
  required by this subsection directly to the provider not later
  than, as applicable:
               (1)  the 30th day after the date the administrator
  receives an electronic claim for those services that includes all
  information necessary for the administrator to pay the claim; or
               (2)  the 45th day after the date the administrator
  receives a nonelectronic claim for those services that includes all
  information necessary for the administrator to pay the claim.
         (c)  Except as provided by Subsection (d), an out-of-network
  provider who is a facility-based provider or a person asserting a
  claim as an agent or assignee of the provider may not bill an
  enrollee receiving a health care or medical service or supply
  described by Subsection (b) in, and the enrollee does not have
  financial responsibility for, an amount greater than an applicable
  copayment, coinsurance, and deductible under the enrollee's health
  benefit plan that:
               (1)  is based on:
                     (A)  the amount initially determined payable by
  the administrator; or
                     (B)  if applicable, a modified amount as
  determined under the administrator's internal appeal process; and
               (2)  is not based on any additional amount determined
  to be owed to the provider under Chapter 1467.
         (d)  This section does not apply to a nonemergency health
  care or medical service:
               (1)  that an enrollee elects to receive in writing in
  advance of the service with respect to each out-of-network provider
  providing the service; and
               (2)  for which an out-of-network provider, before
  providing the service, provides a complete written disclosure to
  the enrollee that:
                     (A)  explains that the provider does not have a
  contract with the enrollee's health benefit plan;
                     (B)  discloses projected amounts for which the
  enrollee may be responsible; and
                     (C)  discloses the circumstances under which the
  enrollee would be responsible for those amounts.
         Sec. 1275.053.  OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
  OR LABORATORY SERVICE PROVIDER PAYMENTS. (a)  In this section,
  "diagnostic imaging provider" and "laboratory service provider"
  have the meanings assigned by Section 1467.001.
         (b)  Except as provided by Subsection (d), the administrator
  of a health benefit plan to which this chapter applies shall pay for
  a covered health care or medical service performed for or a covered
  supply related to that service provided to an enrollee by an
  out-of-network provider who is a diagnostic imaging provider or
  laboratory service provider at the usual and customary rate or at an
  agreed rate if the provider performed the service in connection
  with a health care or medical service performed by a participating
  provider. The administrator shall make a payment required by this
  subsection directly to the provider not later than, as applicable:
               (1)  the 30th day after the date the administrator
  receives an electronic claim for those services that includes all
  information necessary for the administrator to pay the claim; or
               (2)  the 45th day after the date the administrator
  receives a nonelectronic claim for those services that includes all
  information necessary for the administrator to pay the claim.
         (c)  Except as provided by Subsection (d), an out-of-network
  provider who is a diagnostic imaging provider or laboratory service
  provider or a person asserting a claim as an agent or assignee of
  the provider may not bill an enrollee receiving a health care or
  medical service or supply described by Subsection (b) in, and the
  enrollee does not have financial responsibility for, an amount
  greater than an applicable copayment, coinsurance, and deductible
  under the enrollee's health benefit plan that:
               (1)  is based on:
                     (A)  the amount initially determined payable by
  the administrator; or
                     (B)  if applicable, the modified amount as
  determined under the administrator's internal appeal process; and
               (2)  is not based on any additional amount determined
  to be owed to the provider under Chapter 1467.
         (d)  This section does not apply to a nonemergency health
  care or medical service:
               (1)  that an enrollee elects to receive in writing in
  advance of the service with respect to each out-of-network provider
  providing the service; and
               (2)  for which an out-of-network provider, before
  providing the service, provides a complete written disclosure to
  the enrollee that:
                     (A)  explains that the provider does not have a
  contract with the enrollee's health benefit plan;
                     (B)  discloses projected amounts for which the
  enrollee may be responsible; and
                     (C)  discloses the circumstances under which the
  enrollee would be responsible for those amounts.
         SECTION 2.  The heading to Subtitle K, Title 8, Insurance
  Code, is amended to read as follows:
  SUBTITLE K. CERTAIN BENEFITS AND ARRANGEMENTS THAT ARE NOT
  INSURANCE [HEALTH CARE SHARING MINISTRIES]
         SECTION 3.  Subtitle K, Title 8, Insurance Code, is amended
  by adding Chapter 1682 to read as follows:
  CHAPTER 1682. HEALTH BENEFITS PROVIDED BY CERTAIN NONPROFIT
  AGRICULTURAL ORGANIZATIONS
         Sec. 1682.001.  DEFINITIONS. In this chapter:
               (1)  "Nonprofit agricultural organization" means an
  organization that:
                     (A)  is exempt from taxation under Section 501(a),
  Internal Revenue Code of 1986, as an organization described by
  Section 501(c)(5) of that code;
                     (B)  is domiciled in this state;
                     (C)  was in existence prior to 1940;
                     (D)  is composed of members who are residents of
  at least 98 percent of the counties in this state;
                     (E)  collects annual dues from its members; and
                     (F)  was created to promote and develop the most
  profitable and desirable system of agriculture and the most
  wholesome and satisfactory conditions of rural life in accordance
  with its articles of organization and bylaws.
               (2)  "Nonprofit agricultural organization health
  benefits" means health benefits:
                     (A)  sponsored by a nonprofit agricultural
  organization or an affiliate of the organization;
                     (B)  offered only to:
                           (i)  members of the nonprofit agricultural
  organization; and
                           (ii)  family members of members of the
  nonprofit agricultural organization;
                     (C)  that are not provided through an insurance
  policy or other product the offering or issuance of which is
  regulated as the business of insurance in this state; and
                     (D)  that are deemed by the nonprofit agricultural
  organization to be important in assisting its members to live long
  and productive lives.
               (3)  "Preexisting condition" means a condition present
  before the effective date of an individual's enrollment in
  nonprofit agricultural organization health benefits.
         Sec. 1682.002.  NONPROFIT AGRICULTURAL ORGANIZATION HEALTH
  BENEFITS AUTHORIZED. A nonprofit agricultural organization or an
  affiliate of the organization may offer in this state nonprofit
  agricultural organization health benefits.
         Sec. 1682.003.  WAITING PERIOD FOR PREEXISTING CONDITION.
  Notwithstanding any other provision of this chapter, a nonprofit
  agricultural organization that offers nonprofit agricultural
  organization health benefits may not require a waiting period of
  more than six months for treatment of a preexisting condition
  otherwise included in nonprofit agricultural organization health
  benefits.
         Sec. 1682.004.  REQUIRED DISCLOSURE BY NONPROFIT
  AGRICULTURAL ORGANIZATION. (a) A nonprofit agricultural
  organization that offers nonprofit agricultural organization
  health benefits must provide to an individual applying for
  nonprofit agricultural organization health benefits written notice
  that the benefits are not provided through an insurance policy or
  other product the offering or issuance of which is regulated as the
  business of insurance in this state.
         (b)  An individual must sign and return to the nonprofit
  agricultural organization the notice described by Subsection (a)
  before the individual may enroll in nonprofit agricultural
  organization health benefits. The nonprofit agricultural
  organization must:
               (1)  maintain a copy of the signed written notice for
  the duration of the term during which the nonprofit agricultural
  organization health benefits are provided to the individual; and
               (2)  at the request of the individual, provide a copy of
  the written notice to the individual.
         Sec. 1682.005.  NONPROFIT AGRICULTURAL ORGANIZATION NOT
  ENGAGED IN BUSINESS OF HEALTH INSURANCE. Notwithstanding any other
  provision of this code, for the purposes of offering nonprofit
  agricultural organization health benefits, a nonprofit
  agricultural organization that acts in accordance with this chapter
  is not a health insurer and is not engaging in the business of
  health insurance in this state.
         Sec. 1682.006.  RISK TRANSFER OR COVERAGE. A nonprofit
  agricultural organization that offers nonprofit agricultural
  organization health benefits under this chapter may contract with a
  company authorized to engage in the business of insurance in this
  state that is not under common control with the nonprofit
  agricultural organization to:
               (1)  transfer to that company all or a portion of the
  organization's risks arising from nonprofit agricultural
  organization health benefits offered under this chapter; or
               (2)  obtain insurance coverage from the company
  guarantying the nonprofit agricultural organization's obligations
  arising from nonprofit agricultural organization health benefits
  offered under this chapter.
         SECTION 4.  This Act takes effect September 1, 2021.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 3924 was passed by the House on May 5,
  2021, by the following vote:  Yeas 106, Nays 39, 1 present, not
  voting; and that the House concurred in Senate amendments to H.B.
  No. 3924 on May 28, 2021, by the following vote:  Yeas 104, Nays 42,
  2 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 3924 was passed by the Senate, with
  amendments, on May 22, 2021, by the following vote:  Yeas 18, Nays
  11.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor       
feedback